The URL can be used to link to this page

EL-18-1042Miami Shores Village `yeoREs 10050 N.E. 2nd Avenue NE - .. Miami Shores, FL 33138-0000 `moo` Phone: (305)795-2204 't�oRio� Permit NO. EL-4-18-1042 Permit Type: Electrical - Residential Pen ' Work Classification: Addition/Alteration Permit Status: APPROVED issue Date: 6/11/2018 1 Expiration: 12/08/2018 Project Address Parcel Number Applicant 54 NE 95 Street 1132060130470 JUDITH WILLIAMS Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell JUDITH WILLIAMS 54 NE 95 Street (305)756-1312 MIAMI SHORES FL 33138-2707 Contractor(s) Phone Cell Phone ARRIVED ELECTRIC INC (786)597-0250 Type of Work: CHANGE PANEL RESTORATION LIGHT KITC Additional Info: CHANGE PANEL RESTORATION LIGHT KITC Classification: Residential Scanning: 1 Fees Due Amount CCF $3.60 DBPR Fee $3.38 DCA Fee $2.25 Education Surcharge $1.20 Permit Fee - Additions/Alterations $225.00 Scanning Fee $3.00 Technology Fee $4.80 Total: $243.23 Valuation: $ 5,900.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # EL-4-18-67228 06/11/2018 Check #: 100693 $ 193.23 $ 50.00 04/19/2018 Cash $ 50.00 $ 0.00 Ovailahla Insnpctinns! Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical W. W. Underground In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zonkng. -F-laitrmore, I authorize the above -named contractor to do the work stated. June 11,2018 Aut ure:Owner / Applicant / Contractor / Agent Building Department Copy June 11, 2018 1 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS! COMPENSATION CONSTRUCTION INDUSTRY EXEMPTION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE DATE: i131t2018 PERSON: ARRUFAT FEIN; 800SM4 BUSINESS NAME AND ADDRESS: ARRIVED ELECTRIC INC EXPIRATION DATE: 11311'2f 0 ALFREDO E 12478 SW 199TERR MIAN FL SCOPE OF BUSINESS OR TRACE: y .Il♦: f 1;:p1 33177 (0dM/DrfYYY)1DCERTIFICATE OF iABiLITY 11 USCEFDATE 0/6/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER (786) 573-4485 (786) 573-4486 NA. cT SteDhanie Garcia Insurance NOW Agency 9 Y -- PHONE (786 573-4485 _. a°c No : 786�57348 12915 SW 132 Street suite 4-B E-MAIL - _-- ADDRESS: Ste hanie insurancenowaqenCCom iami, FL 33186 PRODUCER _-___................ c TQMERID# __. INSURER S AFFORDING COVERAG. -- Arrived Electric t',orp. ............... INSURERA: GI:arlaths._ a5v_d_n1C$_QOm}�c'�,,,n j___._.—__._............_._..._-_._—. _...... 12478 SW 199 Terr INSURER 8: Miami, Fl- 33177 INSURER C : — .—..._ _..—__.._.._.�__........__..__. _. _ ......................... INSURER D : __---_.._.........__._... _....... .___ INSURER E INSURERF: r`(1UF17AC-ec ...-..�..•.�.�:,...._._-_-- - KCYIa'!1LlIY IV$iMtSCK: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. . _.. _....__—..,.___... INSRF_ _ LTR I TYPE Or INSURANCE?INSR POLICY EFF PO ICY EXP ....._...... wvn POLICY NUMBER MMIDD/YYYY I (MM/DDJY-= I LIMITS A . GENERAL LIABILITY �� COMMERCIAL GENERAL LIABItITY ....._ .._ + j EACH OCCURRENCE i DAMA—E,�O " ' PREM:'SES rt 5 Ea �uence; a EE CLAIMSAFADE LV' OCCUR _L -- .. ..._.. MED EXP (Any one parson) S 1 QQ_ 0185F1-0007(}049-2 515/2018 j 5/5/22013 PERSONAL 8 ADV INJURY _ GENERALAGGREGATE ; PRODJCTS -COMP/OP AC>G L GEN'L AGGREGATE LIMIT APPLIES PER:PRO i POLICY t i I LOC . AUT6MOBILE LIABILITY , 5 COMBINED SINGLE LIMIT I _- ANY AUTO-- (Ea aciderd) i ALL OWNED AUTO:= I BODILY INJURY (Per person) ! $ i _ 1-- SCHEDULED A'JTOS HIRED AUTOS i BODILY INJURY (Per accid ni) i $ _ ( I PROPERTY DAMAGE � .. ..... ..___ $ f ,NON-0WNED AUTOS (Per accident) j. UMBRELLA LtABT. I - -, OCCUR EXCESS IJAB EACH OCCURRENCE $ �_.._. _.....---.-_._.....-_.._......-_._................._..._.._ ______......__—....... + CLAIMS -MADE DFDUCTIBLE AGGREGATE $ , I i---- $ i F. RETENTION _8 WORKERS COMPENSATION - _.. .......... ---_ ...... $ i AND EMPLOYERS* LIABILITY .ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N O=FTCERIMEMDEREXCl.UDED7 ❑ NIA ! WC STATU_ OEH � TORY LII f R ._ _..... __—_ .... ; { E.L. EACH ACCIDENT $ (Mandatory in NH) if describe j ' �E L�OISEASE EA EMPLOYEE $ __.... yes, under DESCRIPTION OF OPERATIONS betoty .._ ,..__ _...... - ... ! E.L. DISEASE • POLICY LIMIT $ DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) License #EC13006802 I 1 .. ,: --^ i c nvL_LJr_ c CANCELLATION Miami Shores Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE'2nd Avenue THE EXPIRATION DATE THEREOF,. NOTICE WILL BE DELIVERED IN Miami Shores, Florida 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTrIZEID 1IVE Stephanie Garcia ©lase 2609 A ORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD n Miami Shores Village r _ kk \Q\Alb Building Department APR 1a 2118 Q/ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ✓ Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 201--+ BUILDING Master Permit No. -SC1 --=I" PERMIT APPLICATION Sub Permit Noei A — inu2 ❑BUILDING (ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP !-�-ry� CONTRACTOR DRAWINGS �_ 106 ADDRESS: NE 9� s / eer Folio/Parcel#: //v Occupancy Type: (OWNER:_Name (I Address,: `A� reif �Y1 the Building Historically Designated: Yes NO t� Load: Construction Type: Flood Zone: BFE: FFE: ee Simple Titleholder): SvztrN---k- NE` a Kr4 ��- L Tenant/Less"ee N`ame't mail: YAIdAiI14 4.b - Stat`T �" 1 S-Zip a;aj( 3 7 V / CONTRACTOR: Company Name: Jul i /(CEO rPC- Phone#: ✓777 •QZ,,50 Address: / 2zI97 City: State: % / .. zip: `3 3 1 �� Qualifier Name: AIfrec o Al7 F,47- State Certification or Registration #: E C /3 dD &$� C�Z Certificate of Competency #: DESIGNER: Architect/Engineer: one#: Address: City: State: Zip: Value of Work for this Permit: $ C 9 Square/Linear Footage of Work: Type of Work: ❑ Addition ElAlteration ❑ New ElRepair/Replace ElDemolition j Description of Work: 1 1 p tic�C IV p Q Z3�-t 'R,e-5 -ha U f-0- f -f N Specify color of color thru tile: Submittal Fee $ Permit Fee $T, 5.db CCF $ CO/CC $ Scanning Fee $ Technology Fee $ Radon Fee $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Structural Reviews $ Bond $ 3 TOTAL FEE NOW DUE $ ��- (Revised02/24/2014) � t Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address city State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. 1 understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant. As a condition to the Issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construc-(on lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issue In the abse ce pf such posted notice, the inspection will not be approved and a reinspection fee will be charged. � r--t Signature VC IN R or AGENT The foregoing instrument was acknowledged before me this l ` . day of�tS �= �,O y , 20 , ('A- ,bY is personally known to me or who has producedC=fit 0 (-t _ .as identification and who did take an oath. NOTARY PUBLIC The foregoing instru nt was acknowledged beforemethis ,�daay of 20 f d' by who is aersonally known to m or who has produce as identification and who did take an NOTARY "Sign., Sign: Print: Ca r� P ��c�r vN or- Print: Seal: f ANA I FERREIRA Seal: Notary Public 2o'W k",,c LUIS FERNANDEZ State of New Jersey * * MY COMMISSION # GG 041161 yrrmi Ion Expires Feb. 28, 2021 *'l��t*�•****#**. EXPIRES: November 7, 2020 ' APPROVED BY /B Plans Examiner Zoning Structural Review Clerk (Revisedo2/24/2014) 01 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIO NAL R ION ,,EGULAT EC13006802 i�,ISSUED: 08/24/2016 UN, CERTIFIED klidb&AL CONTRACTOR ARRUFAT, ALFRO ARRIVED ELECTRIC'!�,C. IS CERTIF ED under the rovislons of Ch.489 FS, Exp1milondat :AUG 31.2018 Li808240003210 r— 007438 Lora ' l usiness Tam Receipt Miami -Dade County, State of Florida - THIS IS NOT A SILL - DO NOT PAY 6670641 BUSINESS NAME/LOCATION ARRIVED ELECTRIC INC 12478 SIN 199 TERR MIAMI FL 33177 CHIP R ARRIVED ELECTRIC INC ALFREDO E ARRUFAT QUALIFIER Worker(s) 1 RECE1" NM RENEWAL 6942818 ..P. .. _.. EXPIRES Must be displayed at place of business Pursuant to County Code Chapter 9A — Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 07/20/2017 CR E D ITCARD--17 •-0 491.14 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit or a certification of the holder's qualifications, to do business. Holder must com I w' or nongovernmental regulatory laws and requirements which apply to the business, ply 1th any governmental The RECEIPT NO. above must he displayed on all commercial veitiq Ca For more information, visit . 4t , SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR EC13006802 . ... .71 \ .S ACCPREP CERTIFICATE OF LIABILITY INSURANCE `-- DATE(MMMONYYY) 1 01 /29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s . PRODUCER (786) 573-4485 (786) 573-4486 Insurance NOW Agency 12915 SW 132 Street suite 4-B Miami, FL 33186 VME T Stephanie Garcia PHONE 786 573-4485 FAIL No): 786 573-4486 EAD�DRELu: stephanie@insurancenowagency.com PRODUCER INSURE S AFFORDING COVERAGE NAIC / INSURED Arrived Electric Corp. 12478 SW 199 Terr Miami, FL 33177 INSURER A: Granada Insurance Company INSURERS: INSURER C : INSURERD: INSURER E : INSURER F : L.UVCr%A%3C0 GtKIIFIUA II- NIIMHFK• 0C%A0ir%U U uan Cn. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBN POLICY NUMBER POLICY EFF MPMIO DD (YYYYY LIMITS GENERAL LIABILITY A EACH OCCURRENCE $1-000,000 RENTED PREMISES Ea occurrence $100,000 COMMERCIAL GENERAL LIABILITY © MED EXP (Any one Person) $ CLAIMS -MADE OCCUR 0185FL00070049-2 5/5/2017 5/5/2018 PERSONAL & ADV INJURY $1.000,000 GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON -OWNED AUTOS $ $ UMBRELLA LlAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DEDUCTIBLE a $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEWMEMBER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 1 M, Additional Remarks Schedule, if more space Is requlmd) License #EC13006802 Location: Gen & Elizabeth Lot 24 Miami Shores Building Department 10050 NE 2nd Ave Miami Shores, FL. 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Stephanie Garcia W I VUtl-ZUU9 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD fto DE Tm IDIV;1400 -IFINAMPLAL aEnvic CON TRCr UST R CE"17F1CATE OF 8XCTjoAlr D BE COMPEWa7joU o WS PT FROM FI.,OM10A ' t r La,A�T�, r 4/22/201 B ' ° ENRAMON DATA 4122/2018 r ARRUFAT r ALFREDO i fi b" 800588624 � r D ""'S iVAPL4E API t � ADDR��;: r ARRIVED ELECTRIC #WC w 1 478 SVV 199TH TER lWWWWADE t FL 33177 M� SCOPES OF BUSINESS CAR TRA ONTRACTOR aw ow Proof of Coverage Page 1 of 1 WC M1tobile App WC Home Search Our Data CFO home Employer Detail Page 'I'his database was last updated 'Thursday, May 1.7, 2018 12:06 AM. Carrier Location Information Return to Search Page Employer Information Employer Name Employer Type NAICS Code (ARRIVED ELECTRIC INC (CORPORATION IN/A Coverage History INo Coverage History Exemption Listings Exemption Holder Name - Click on the name(s) below to view more detailed information ALFREDO E ARRUFAT Owner Election Listings No Owner Election of Coverage Listings Employer Name History Employer Name Name Type Change Date (ARRIVED ELECTRIC INC I Legal lCurrent Return to Search Page https://apps8.fldfs.com/proofofcoverage/EmployerDetail.aspx?EmpID=004100250 5/17/2018 Proof of Coverage Page 1 of 1 WC Mobile: 3pp WC 110111P Search Our Data CFO 11olne Exemption Detail Page This database was last updated Thursday, May 17, 2018 12:06 AM. Return to Previous Page I Exemption Details Name Title Effective Data I -Termination Date Exemption Type "'Business Activities Employer Name ALFREDO E ARRUFAT PR Apr 22 2016 Apr 22 2018 Construction Click Here to View i ARRIVED Activities Listed on ELECTRIC INC Exemption I ALFREDO E ARRUFAT PR May 21 2012 May 21 2014 Construction Click Here to View ARRIVED Activities Listed on ....----"---- ..—.—_...... ELECTRIC INC Exemption ALFREDO E ARRUFAT PR Jun 14 2010 May 21 2012 Construction Click Here to View ARRIVED Activities Listed on Exemption ELECTRIC INC ALFREDO E - ARRUFAT Jan 31 2018 Jan 31 2020 I Construction Click Here to ViewRRIVEDELECTRIC Activities Listed on IINC Exemption ALFREDO E Click Here to View �ARRIVEDELECTRIC ARRUFAT PR Mar 30 2016 Jan 31 2018 Non Construction Activities Listed on INC Exemption ALFREDO E ARRUFAT PR May62014 Mar302016 I Construction Click Here to View ARRIVEDELECTRIC Activities Listed on Exemption INC "Termination may be through the revocation of the exemption, or expiration of the exemption. **The exemption only applies to the business activities listed on the exemption. Return to search Page https:Happs8.fldfs.com/proofofcoveragelExemptionDetail.aspx?pr_person_id=004386O60 5/17/2018 ARRIVED ELECTRIC INC 12478 SW 199 TERR MIAMI, FLORIDA 33177 786 597 0250 Date: v5 1/ �� State of: t�l4i�ir County of- Before44 me this day personally appeared who, being duly sworn, deposes and says: That he or she will be tPeponly person working in the project at: 6q/ " IAjciui Shav"O-d Contra for Signa e Sworn to (or affirmed and subscribed before me on this day of 2019 by Personally known OR Produced Identification Type of Identification Produced "'}�%•;.: RAYMON ACALLAO ISSIO # GG030912 a ri.,,• 20 Print, Typ or Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Com'Densation Insurance Exem Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. StaL § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if- 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the ininimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited -liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensadon exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's coirrpany for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signaturet&en(.A k J - r Aev State of*Wgdda- r O Kr. New Y0A Ic County of adiant Dade. The foregoing was acknowledge before me this IN day of 20_[-- By, iN1 f C H �9t G P. lv l lrL i A 1M.� who is personally known to me or has produced N J 'O KWGICS Ll tie► S c as identification. Notary: G SEAL: EMMANt1EL LAFORTUNE NOTARY PUBLIC, STATE OF NEW YORK QUAMW in Kings Cmmty Commirsioa Expires 08M7/2021 ', G aOTA y'm SUB 00 : •. ,of ENO